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. Author manuscript; available in PMC: 2025 Oct 1.
Published in final edited form as: Clin Gerontol. 2023 Sep 19;47(5):862–869. doi: 10.1080/07317115.2023.2260815

Changes in Depressive Symptoms of Korean American Dementia Caregivers after Attending the Savvy Caregiver Program: Preliminary Findings with a Pilot Sample

Yuri Jang 1,2, Kenneth Hepburn 3, Juyoung Park 1, William E Haley 4, Miyong T Kim 5
PMCID: PMC10948376  NIHMSID: NIHMS1932366  PMID: 37724817

Abstract

Objectives

Language accommodation is indispensable in making evidence-based interventions available and accessible to ethnic minorities with limited English proficiency. As part of the larger effort to culturally adapt the Savvy Caregiver Program for Korean American dementia caregivers, we first conducted linguistic adaptation, and the present study reports the preliminary findings on participants’ changes in depressive Symptoms.

Methods

The linguistically adapted program was delivered to two small groups of Korean American dementia caregivers (total n = 13) by two Savvy-certified Korean-speaking trainers. Participants’ depressive symptoms were assessed at three time points (pre-intervention, immediate post-intervention, and 6-month follow-up).

Results

Following the intervention, participants exhibited lowered depressive symptoms (t = 8.64, p < .001, Cohen’s d = .89). This benefit was sustained at 6-month follow-up.

Conclusions

Findings suggest that the therapeutic benefit of the Savvy Caregiver Program could potentially be shared with linguistic minorities when delivered in their native language.

Clinical Implications

Although limited in its scope and nature, the pilot study with linguistic adaptation sheds light on efforts to close the gap in the evidence-based intervention delivery.

Keywords: Evidence-based intervention, dementia caregivers, older immigrants, Korean Americans, limited English proficiency

Introduction

Dementia caregivers in ethnic minority communities have often been excluded from access to caregiver interventions and their benefits because of linguistic and cultural barriers (Cheng et al., 2020; Gallagher-Thompson et al., 2003). In pursuit of equal treatments for all, it is imperative to make evidence-based interventions available and accessible to ethnic minority dementia caregivers, and linguistic and cultural adaptation is indispensable for reaching out to them (Bernal et al., 2009; Parker et al., 2023).

Focusing on Korean Americans as a target group and using the Savvy Caregiver Program (SCP) as an evidence-based intervention, we adapted the SCP to be appropriate for Korean American dementia caregivers with limited English proficiency. Based on the steps of cultural adaptation suggested by Barrera and colleagues (2011), our data-driven adaptation was initiated with linguistic attunement. Its implementation with a small group of trainers and caregivers yielded quantitative and qualitative data, which guided the subsequent step of full adaptation conducted via a feedback loop among various stakeholders including the SCP originator (KH) and research and community partners. The program’s feasibility and acceptability outcomes, as well as the process of cultural adaptation and recommendations for modifications, are published elsewhere (Jang et al., 2022). In the present study, we report the preliminary findings on how participants’ symptoms of depression change after participating in the linguistically adapted SCP.

The SCP is an evidence-based dementia caregiver psychoeducational program (Hepburn, Lewis, Sherman et al., 2003; Hepburn, Nocera, Higgins et al., 2022). Grounded in social cognitive theory (Bandura, 1989), the SCP targets the enhancement of caregiver self-efficacy in order to promote effective coping responses to stressful situations, with better caregiving outcomes (Hepburn, Lewis, Sherman et al., 2003; Hepburn, Nocera, Higgins et al., 2022). The program is delivered by Savvy-certified trainers in person or online, using such strategies as instruction, modeling, active learning, and coaching. The course content of the 6-week program includes introduction to dementia, caregiver self-care, the effect of dementia on the performance of everyday tasks and activities, “contented involvement” (helping caregivers remain calm and pleasant while interacting with the care recipient), a decision-making guide for family caregivers, and strengthening family caregiving arrangements. In addition to improving caregiving skills, knowledge, and confidence, the SCP has been found effective in reducing depressive symptoms in diverse groups of dementia caregivers (Hepburn, Lewis, Sherman et al., 2003; Hepburn, Nocera, Higgins et al., 2022; Sepe-Monti, Vanacore, Bartorelli et al., 2016). The SCP has been widely adopted by community-based organizations and state agencies and successfully implemented in community settings (Hepburn, Nocera, Higgins et al., 2022; Sepe-Monti, Vanacore, Bartorelli et al., 2016). However, its benefits have rarely been shared with non–English-speaking ethnic minorities (Kally, Cote, Gonzalez et al., 2014).

Our selection of Korean Americans as a target group is based on their notably high language barriers; Korean is the fourth most common language spoken by U.S. populations with limited English proficiency (Batalova & Zong, 2016; Budiman, 2021). Korean Americans are also known to have a high level of caregiving burden and depressive symptoms (Casado et al., 2018; Kim et al., 2006; Lee & Farran, 2004), to be subject to misconceptions and stigmatization of dementia (Jang et al., 2010; Lee et al., 2021), and to lack access to dementia-related resources and services (Park et al., 2021). Several features of the SCP seem to be relevant to Korean Americans. First, in Korean cultures where teaching and learning is highly valued and concrete goals are preferred to abstract thinking (Hong & Ham, 2001; Shin & Lukens, 2002), SCP’s problem-focused psychoeducational approach would be considered appropriate. Studies also show that the sense of mastery or control, closely linked with the SCP’s core construct of self-efficacy, is an important psychological asset of Koreans (Jang et al., 2006; Kim et al., 2005). We believed that if the SCP was delivered in a linguistically appropriate manner (i.e., with a Korean version of the SCP manual and with delivery by a Korean-speaking interventionist), Korean American dementia caregivers would benefit from the program. As part of the larger effort to culturally adapt the SCP for Korean American dementia caregivers, in the present study, we report preliminary findings on the impact of the linguistically adapted SCP on depressive symptoms with a pilot sample of Korean American dementia caregivers.

Methods

Linguistically Adapted Program Development

Two individuals proficient in English and Korean translated the original SCP caregiver manual (290 pages in length) into Korean, and two other individuals reviewed the drafted version. To ensure the quality, the draft was reviewed and refined by a panel of bilingual and bicultural researchers with expertise in aging, caregiving, behavioral interventions, and Korean cultures (n = 6). Next, using a community health worker model (Islam et al., 2017), we recruited two community members who were bilingual in English and Korean to serve as Savvy trainers. Both were middle-aged women and were college graduates with work experience in human services; neither had formal training in dementia or personal caregiving experience. To become certified Savvy trainers, they received training via an online program developed by SCP authors with funding from the National Institute on Aging (R01AG061971) and delivered by the Emory University Nursing Experience. The SCP’s multiple training modules offer instruction on the program’s core principles and training mechanism as well as preparation for conducting SCP group sessions (Hepburn, Nocera, Higgins et al., 2022). The trainers’ understanding and competence are evaluated with a quiz and short essay at the end of each module. Our trainers spent about 30–35 hours in completing training and certification. The trainers also had an online meeting with the Savvy originator (KH) to discuss Savvy’s core values and principles. During program implementation, they were assisted by weekly pre-session preparation and post-session debriefing meetings with the project lead (YJ), who was also bilingual in English and Korean. Because the Savvy training was conducted in English with the original manual, it was necessary to prepare them to deliver the course in Korean. All sessions were observed by the project lead (YJ) and coordinator (JP), and fidelity was evaluated by using the Savvy Performance Checklist (Hepburn, Lewis, Sherman et al., 2003). Ratings for all sessions were over 90%.

Recruitment and Implementation

The project was conducted with approval from the Institutional Review Board at the University of Southern California. All procedures were performed in accordance with ethical principles, and informed consent was obtained from all participants. Self-identified Korean Americans residing in the greater Los Angeles area who were caregivers of a family member with dementia, spoke English less than very well, had access to computer and the Internet, and scored lower than 20 on the Patient Health Queationnaire-9 (PHQ-9; Kroenke et al., 2001) were eligible to take part in the study. Because the SCP is not a mental health treatment program, exclusion of those with severe depression (PHQ-9 score ≥20) was necessary. As a safety protocol, a list of local mental health service providers including Korean-speaking counselors was prepared; however, no case of severe depression was identified at screening. We originally intended to recruit 12 participants (six in each trainer’s class) but ended up with 13. Our recruitment sources were multiple, including a previously established network of dementia caregivers, public advertisement, and referrals from social service providers. During February and March, 2022, each trainer delivered the linguistically adapted SCP to the six or seven participants. The SCP sessions were delivered via Zoom on Saturdays for 6 weeks (with one trainer’s class in the morning and the other’s in the afternoon), and each session lasted 75 minutes.

Prior to program implementation, an individual Zoom meeting was scheduled with each participant to explain the project, offer an opportunity to ask questions, and obtain informed consent. All participants were informed that the SCP sessions would be observed by research staff and recorded for research purposes. During these meetings, baseline depressive symptoms were assessed along with sociodemographic characteristics and caregiving contexts (e.g., relation to the care recipient, years of caregiving). A brief tutorial on basic Zoom functions was also provided.

Assessment

Post-intervention assessment was conducted within one week after completion of the program. Along with standardized measures, a qualitative approach was used to solicit participants’ feedback about the program. An hour-long individual interview was conducted with each participant. It should be noted that the interviews focused on cultural relevance of the program and areas for improvement. Hence, qualitative data specific to emotional state of caregivers were limited. Participants were re-contacted in 6 months to follow up on their depressive symptoms using a quantitative measure. In the present study, we mainly report the results from the quantitative data analyses. When applicable in the discussion section, qualitative data were used to contextualize the findings from quantitative analyses.

The quantitative measure of program efficacy was the PHQ-9 (Kroenke et al., 2001). As a depression module for the PHQ (Spitzer et al., 1999), the PHQ-9 contains nine items based on symptoms of depressive disorders in the Diagnostic and Statistical Manual of Mental Disorders. Participants are asked to report how often, over the past two weeks, they have been bothered by problems such as “little interest or pleasure in doing things,” “feeling down, depressed or hopeless,” and “trouble falling or staying asleep or sleeping too much.” Each item is scored on a 4-point scale ranging from 0 (not at all) to 3 (nearly every day). Total scores can thus range from 0 to 27, with higher scores indicating greater depressive symptom severity. The scale has been translated into Korean, and its psychometric properties have been validated (Han et al., 2008). In a study with older Korean Americans (Jang et al., 2012), the PHQ-9 was found to be closely linked with other measures of depressive symptoms.

Results

A total of 13 Korean American dementia caregivers were recruited for the SCP, and all met the inclusion criteria. Descriptive characteristics of the sample are summarized in Table 1. The age of the participants ranged from 31 to 70 years, with a mean age of 54.2. Approximately 85% were women, over 15% were not married, about three quarters had more than a high school education, and 54% were employed. All participants were born in Korea, used Korean as their primary language, and spoke English less than very well. Their number of years lived in the U.S. ranged from 18 to 44, with an average of 27.1 (SD = 7.93). About half of the participants were caring for their own parent, 30.8% for a parent-in-law, 15.4% for another relative, and 7.7% for a grandparent. Years of caregiving ranged from 2 to 7, with a mean of 3.75. The age of care recipients averaged 87.7 years (range, 66–101), and a majority of care recipients (92.3%) were women.

Table 1.

Descriptive Summary of Participating Caregivers

Age Relation to
Patient		 Age of
Patient		 Years of
Caregiving		 Number of
Sessions
Completed		 PHQ-9 at
Pre-test		 PHQ-9 at
Post-test		 PHQ-9 at
6-month
Follow-up
Mrs. K 68 Daughter 97 5 6 14 11 10
Mrs. M 53 Daughter-in-law 85 14 6 15 12 12
Mrs. P 55 Niece 72 10 6 14 13 13
Ms. H 32 Granddaughter 85 3 6 18 17 —
Mrs. S 59 Daughter 95 4 6 12 10 11
Mrs. L 60 Niece 87 1 6 15 12 11
Mrs. E 59 Daughter 89 3 6 17 15 16
Mr. DK 70 Son 96 10 6 14 13 12
Mrs. R 58 Daughter 92 3 6 14 12 13
Mr. JP 63 Son 90 15 6 15 13 11
Mrs. MK 39 Daughter-in-law 66 3 5 18 16 12
Mrs. N 58 Daughter 84 5 6 12 10 11
Mrs. HE 31 Daughter-in-law 100 4 6 16 12 13
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Over the 6-week period of program implementation, there was no attrition. All but one participant completed all six sessions (session completion rate = 98%). On two occasions, a participant attended the other SCP class due to a schedule conflict with the participant’s regular SCP class. Pre- and post-intervention assessment data were available for all participants; however, follow-up data were missing for one individual who was unreachable with three tries. Depressive symptom scores at the three assessment points are depicted in Figure 1. Baseline data indicate that the overall mental health status of the sample was poor; PHQ-9 scores ranged from 12 to 18 with a mean of 14.9 (SD = 1.93). Group means at post-intervention and 6-month follow-up were 12.7 (SD = 2.12) and 12.8 (SD = 1.56), respectively. It was notable that all participants showed some degree of reduction in their depressive symptoms upon completion of the SCP. We conducted paired t-tests to quantify the changes in depressive symptom scores between assessment points. Upon completion of the program, the sample experienced an average reduction of 2.15 points (SD = .89) in PHQ-9 scores, and the difference was statistically significant (t = 8.64, p < .001). Cohen’s d revealed that the difference between the means was a large effect (d = .89). No significance was found in score differences between post-intervention and follow-up assessments (t = .74, p = .47), indicating that the program’s benefit was sustained after 6 months. It should be noted that due to the small sample size, caution should be exercised in interpreting the statistical outcomes. However, the overall findings suggest a potential therapeutic benefit of the linguistically adapted SCP and warrant further investigation.

Figure 1.

Figure 1.

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Changes in Depressive Symptom Severity among Participants

Discussion

Given that language accommodation is indispensable in making evidence-based interventions available and accessible to ethnic minorities with limited English proficiency (Bernal et al., 2009; Parker et al., 2023), in the present study we adapted the SCP linguistically for Korean American dementia caregivers. Adding to the program’s positive feasibility and acceptability, as well as the details of the cultural adaptation process and recommended modifications, published elsewhere (Jang et al., 2022), here we report how it yields mental health impacts on caregivers. After completing the program, all participants showed some degree of reduction in their depressive symptoms. Although the pattern and extent of change did vary among participants, the score difference between post-intervention and 6-month follow-up was statistically significant, but the reduction did not reach the generally recommended standard of an average of 5-point reduction on the PHQ-9 (Kroenke, 2012). While the intervention had a sizeable effect size, effect sizes can be inflated in small samples (Hedges & Olkin, 2014), suggesting further caution is necessary in interpreting the results, and a need for a trial with a larger sample size.

Along with the notably high retention rate, the response in depressive symptoms suggests the needs for psychoeducational programs among Korean American dementia caregivers that have not been met. Despite the widely known challenge of recruiting and retaining ethnic minorities in dementia-related research, services, and clinical trials (Brijnath et al., 2022; Gilmore-Bykovskyi et al., 2019) and cultural stigmatization related to dementia in Korean Americans (Casado et al., 2018; Jang et al., 2010; Lee et al., 2021; Park et al., 2021), the SCP was strongly endorsed by our study participants. Participants appreciated the educational opportunity to learn about dementia. During their interviews, participants often mentioned core SCP values such as the persistence of personhood, contented involvement, and self-care, which suggests that Savvy principles were delivered successfully. It was also acknowledged that the concept of self-care was new and that the SCP helped them realize its importance. Overall, the findings support the relevance of the SCP for Korean Americans, whose culture emphasizes learning and teaching (Hong & Ham, 2001; Shin & Lukens, 2002), with sense of control as a psychological asset (Jang et al., 2006; Kim et al., 2005).

Beyond their educational gain, the participants also seem to enjoy emotional benefits. The potential therapeutic effect may be attributable to the cognitive and behavioral goals of the SCP—to alter the perspectives and attitudes of participants who are experiencing caregiving stress, and to empower them via enhanced self-efficacy. During their interviews, participants mentioned different types of psychological gain, including a sense of community, optimism, and the courage to talk about personal emotions. Two caregivers stated that they became interested in receiving mental health counseling after participating in the SCP. Participant MK, for example, said that she felt much better after she shared her situations and emotions during SCP sessions. This experience led her to schedule an appointment with a Korean-speaking counselor. Her baseline depression score was the highest and the slope of her symptom reduction was the steepest. This pattern of decline continued during the 6-month follow-up period. Her experience with SCP seemed to empower her to seek much-needed assistance for her mental health, and this improved her emotional state. In addition to commenting on the program’s benefits, participants provided valuable input regarding cultural relevance of the SCP. Using a feedback loop involving the SCP’s originator (KH) and research and community partners and balancing fit and fidelity (Barrera et al., 2011; Bernal et al., 2009), we were able to recommend refinements to the SCP (Jang et al., 2022). Examples include augmenting course contents to reframe the seemingly individualistic SCP values in the collectivistic cultures (e.g., introducing self-care as a way to improve the well-being of the care recipient and the whole family), setting rules and expectations for group discussion addressing traditional culture influenced communication styles (e.g., modesty, self-effacement), using culturally relevant examples, and replacing some photos in the manual with those featuring Korean/Asian individuals (Jang et al., 2022). Resulting in a refined set of educational materials and implementation guidelines, the fully adapted program is branded as K-Savvy, and it is anticipated to offer further enhanced therapeutic benefits.

Several limitations to the present study should be noted. First, we used a small sample in a single geographic location, limiting generalizability. Also, our sample did not include spousal caregivers, who tend to be under-resourced. Given that caregivers with advanced age are more likely to have language barriers and to be disadvantaged in computer usage and Internet access, future studies should attend to their needs. It should also be noted that our pilot testing was based on a single group pre/post/follow-up design without a control group. This design was adequate for a pilot intervention to test preliminary efficacy (Julious, 2005), but to build strong evidence, one needs a larger, more diverse sample of caregiver participants in a randomized controlled design. Building upon preliminary findings, K-Savvy warrants rigorous testing of efficacy in consideration of a threat to internal validity (e.g., research reactivity or social desirability). Also, attention should be paid to exploring the mechanisms of change (i.e., whether the improved caregiver outcome is mediated through enhanced self-efficacy). Because the use of qualitative data was limited in the present study design, future studies should fully incorporate mixed methods. Given the potential therapeutic benefit of delivering the SCP to a language minority in a linguistically, culturally appropriate manner, future research should develop a rigorous train-the-trainer program to maintain the culturally adapted SCP’s integrity and broaden its reach and impact.

Clinical Implications.

  • Linguistic adaptation is a promising method to close a gap in the intervention delivery.

  • When delivered in a culturally and linguistically appropriate manner, the benefit of evidence-based dementia caregiver interventions could be shared with caregivers with limited English proficiency.

Acknowledgements:

Data collection was supported by a grant from the National Institute on Aging (R21AG071790, PI: Yuri Jang, PhD). The authors thank caregivers and trainers (Jina Kim and Sooyeon Yoon) who participated in the program, as well as community and research partners who provided comments during the process of cultural adaptation.

Data Availability Statement:

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to the containing information that could compromise the privacy of research participants.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to the containing information that could compromise the privacy of research participants.

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